Daily Archives: April 23, 2012

Patient Presentation A 1-month-old female came to clinic with a 2 day history of increased vaginal discharge. The mother noted that there was an increase in the amount but that the discharge continued to be clear-colored and have a thin consistency. The infant had had increased amounts of stools 4 days ago and the mother noted a red rash on the perineum that she had been using a barrier cream on. The infant was otherwise asymptomatic, and the mother had no concerns about potential sexual or physical abuse. The past medical history revealed a full-term infant female.

The pertinent physical exam showed a well-appearing female growing on the 10-50% growth curves and with normal vital signs. Her perineal area showed moderate generalized erythema of the convex and concave areas of the perineum, labia and buttocks. There were satellite lesions on lower abdomen and inner thighs. Normal appearing vaginal secretions were seen. Her anatomical structures were normal in appearance. The diagnosis of candidal diaper dermatitis causing vulvovaginitis was made and anti-fungal cream was recommended. The mother was educated about normal changes in vaginal secretions in young children.

DiscussionVulvovaginitis can occur at any age but is a very common problem in prepubscent females. In this age group it is often caused by irritants and non-specific inflammation. In adolescents and adult females, sexually transmitted infections become another common problem. Sexual abuse can occur at any age.

Normal vaginal secretions are usually thin, and clear to white with a variable amount. Vaginal discharge that is a different consistency, malodorous, accompanied by blood, pain, pruritis, or dysuria is usually not physiologic. Abdominal pain, emesis and fever may indicate pelvic inflammatory disease.

Non-specific vaginal discharge is usually treated by removing the irritant, sitz baths and education about proper hygiene and increasing air flow to the area. Treatment should also be given for specific causes

Learning Point
The differential diagnosis of vulvovaginitis includes:

Normal variation

Newborn – thin discharge, may have blood with estogen withdrawal

After newborn through puberty – thin mucoid discharge

After puberty – leukorrhea – thin, clear to yellow, not malodorous

Pregnancy – may increase the amount

Irritants – one of the most common causes

Poor hygiene

Bubble bath and soaps

Douches, spermicides, and latex

Masturbation

Restrictive clothing

Infectious – may be due to actual infection and/or abnormal balance of vaginal flora

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

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